Mosaicplasty in the Treatment of Osteochondral Lesions of the Talus: A Report of Two Cases.

Osteochondral damage to the talus is one of the most frequent causes of ankle pain. In contrast to other joints in the lower limb, osteochondral damage of the talus is often attributed to traumatic events. One option of treatment is mosaicplasty, which has proved to be a feasible choice for the treatment of osteochondral lesions of the talus; it has the potential to alleviate ankle pain and facilitate engagement in daily activities as well as sports. We present two different cases of osteochondral lesions of the talus, illustrating how this pathology can present clinically. Both cases involve males with no notable pathological antecedents. The first was the victim of a traffic accident, the second was the victim of a sports accident; they were admitted for the management of chronic ankle pain unimproved by analgesic treatment. Radiological findings revealed a talus osteochondral lesion in both patients, treated with an osteochondral autograft from the homolateral knee. Both patients progressed well, with the resumption of daily activities and sports. The notable result of current research is that mosaicplasty has been shown to have good results in those with large osteochondral lesions who want to return to normal activity.

Functional performance of a bi-layered chitosan-nano-hydroxyapatite osteochondral scaffold: a pre-clinical in vitro tribological study.

Osteochondral grafts are used for repair of focal osteochondral lesions. Autologous grafts are the gold standard treatment; however, limited graft availability and donor site morbidity restrict use. Therefore, there is a clinical need for different graft sources/materials which replicate natural cartilage function. Chitosan has been proposed for this application. The aim of this study was to assess the biomechanics and biotribology of a bioresorbable chitosan/chitosan-nano-hydroxyapatite osteochondral construct (OCC), implanted in an in vitro porcine knee experimental simulation model. The OCC implanted in different surgical positions (flush, proud and inverted) was compared to predicate grafts in current clinical use and a positive control consisting of a stainless steel graft implanted proud of the cartilage surface. After 3 h (10 800 cycles) wear simulation under a walking gait, subsidence occurred in all OCC samples irrespective of surgical positioning, but with no apparent loss of material and low meniscus wear. Half the predicate grafts exhibited delamination and scratching of the cartilage surfaces. No graft subsidence occurred in the positive controls but wear and deformation of the meniscus were apparent. Implanting a new chitosan-based OCC either optimally (flush), inverted or proud of the cartilage surface resulted in minimal wear, damage and deformation of the meniscus.

A comprehensive review of hip arthroscopy techniques and outcomes.

Transforming the orthopedic landscape, hip arthroscopy pioneers a minimally invasive surgical approach for diagnosing and addressing hip pathologies. With its origins dating back to Burman's 1931 cadaveric study, this groundbreaking technique gained clinical relevance in 1939 through Takagi's report. However, the 1980s marked the actual emergence of hip arthroscopy for treating a wide range of hip disorders. Now, a staple in modern orthopedics, hip arthroscopy empowers patients with previously undiagnosed and untreated hip conditions, enabling them to obtain relief and reclaim their lives. By employing a compact camera and specialized tools, surgeons expertly navigate the hip joint, performing procedures from excising loose bodies and mending labral tears to addressing femoroacetabular impingement and tackling other intricate issues. This innovative approach has dramatically elevated patients' quality of life, allowing them to embrace targeted treatments and resume daily activities without resorting to lifestyle alterations.

Surface morphology of osteochondral grafts harvested from femoral condyles with free-hand technique: a cadaveric study.

PURPOSE: The purpose of this cadaver study was to examine the surface morphology of the osteochondral grafts harvested from the femoral condyles using the free-hand graft harvesting technique. MATERIALS AND METHODS: One hundred osteochondral grafts were harvested with 6.5 mm chisels at ten different donor sites using the free-hand technique in five paired knee specimens (Mean age: 56.4 years). The cartilage and subchondral bone surface angles were measured through multiplanar reconstruction computerized tomography examination. The cartilage thickness was measured with a MicroScribe G2X digitizer with an accuracy of 0.02 mm. An acceptable congruity could be obtained when these plugs were transferred to a perpendicular socket (articular step-off of less than 1 mm and 0.5 mm) was evaluated. RESULTS: Four plugs were damaged or broken during harvesting due to technical difficulties; thus remaining 96 plugs were analyzed. The cartilage thickness varied between 1.36 mm and 3.26 mm across the donor sites. The cartilage was the thinnest in the medial intercondylar notch and thickest in the lateral supracondylar notch. Twenty of ninety-six plugs (20.8%) had unacceptable cartilage surface inclination according to the > 0.5 mm protrusion criteria. Of these plugs, 14 were harvested from the lateral intercondylar notch, whereas five of 96 plugs (5.2%) had unacceptable cartilage surface inclination according to the > 1 mm protrusion criteria. Of these plugs, all were harvested from the lateral intercondylar notch. CONCLUSIONS: High rates of unacceptable plugs (up to 100%) might be harvested from the lateral intercondylar notch. In large chondral lesions that require multiple plugs, lateral and medial supracondylar ridges were the best donor sites for perpendicular plug harvesting, whereas lateral intercondylar notch should be avoided.

The regenerative treatment of costal osteochondral graft implantation for partial growth arrest using a rabbit model.

PURPOSE: To investigate the feasibility of cylindrical costal osteochondral graft transplantation as a novel regenerative treatment in growth arrest. METHODS: The medial portion of the proximal tibial growth plate of 6-week-old male New Zealand White rabbits was resected to establish an experimental model of partial growth plate injury. The rabbits were divided into four groups: no-treatment, bone wax transplantation, costal chondral graft, and costal osteochondral graft groups. Radiographic and micro-computed tomography scan results were analyzed to evaluate angular deformity of the tibia and bony bridge formation at the injury site. In addition, repair of the injured growth plate cartilage was assessed histologically at 4, 8, and 12 weeks postoperatively. RESULTS: Radiographic examination revealed that bone wax transplantation continuously decreased the medial proximal tibial angle (MPTA) while the costal chondral graft implantation reduced the decrease of MPTA at 12 weeks postoperatively. The costal osteochondral graft implantation recovered the MPTA, close to the normal. Histologically, the costal osteochondral grafts retained the MPTA in the injured site compared to costal chondral grafts. Additionally, hypertrophic chondrocytes were observed at the graft site in the costal osteochondral graft group at 12 weeks, suggesting that endochondral ossification may occur at the graft site similar to normal ossification. The fluorescence in situ hybridization analysis of osteochondral grafts transplanted from male to female rabbits indicated that they were replaced by cells of host origin. CONCLUSION: The costal osteochondral graft can achieve regeneration without bony bridge formation in partial growth plate injury.

The Combination of Glucocorticoids and Hyaluronic Acid Enhances Efficacy in IL-1ß/IL-17-Treated Bovine Osteochondral Grafts Compared with Individual Application.

Patients with knee osteoarthritis often receive glucocorticoid (GC) or hyaluronic acid (HA) injections to alleviate symptoms. This study evaluated the impact of Triamcinolone Hexacetonide (a GC), HA, and a combination of both on bovine osteochondral grafts exposed to IL-1ß and IL-17 in an ex vivo culture. Metabolic activity increased with GC treatment. GCs and GCs/HA counteracted cytokine effects, with gene expressions similar to untreated controls, while HA alone did not. However, HA improved the coefficient of friction after two weeks. The highest friction values were observed in GC-containing and cytokine-treated groups. Cytokine treatment reduced tissue proteoglycan content, which HA could mitigate, especially in the GC/HA combination. This combo also effectively controlled proteoglycan release, supported by reduced sGAG release. Cytokine treatment led to surface cell death, while GCs, HA, or their combination showed protective effects against inflammation. The GC/HA combination had the best overall results, suggesting its potential as a superior treatment option for osteoarthritis.

Press-Fit Hemihamate Arthroplasty for the Proximal Interphalangeal Joint.

Background Chronic proximal interphalangeal joint fracture-dislocations with articular malunion are complex injuries. Hemihamate arthroplasty is an established technique for the management of both acute and chronic cases but is associated with several complications. We present the clinical experience of modified press-fit hemihamate arthroplasty. Description of Technique The base of the middle phalanx was exposed from the volar side, and the cartilage defect of the proximal interphalangeal joint (PIPJ) was evaluated in the hyperextended position. A bone hole was created slightly toward the volar side to recreate the curvature of the PIPJ. The hemihamate osteochondral graft was harvested and fixed into the bone hole in a press-fit manner without using a screw. The volar plate and flexor tendon sheath were then reattached. Patients and Methods The study included three patients with chronic dorsal fracture-dislocations of the PIPJ. All patients were treated for >6 weeks after the injury (average 11 weeks). Results The average total arc of motion of the affected joint improved from 38 degrees before surgery to 80 degrees after surgery. Radiographically, bone union and congruity of the joint surface were achieved in all the patients. None of the treated patients complained of resting pain and reported minimal pain during activity (average visual analog scale 0.5; range 0-1.4). Conclusions Press-fit hemihamate arthroplasty is a safe and effective procedure for treating chronic PIPJ fracture-dislocations without the risk of screw protrusion.

Hemi-capitate Arthroplasty for Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Surgical Technique and Illustrative Case.

Osteochondral graft from the carpal bone allows anatomical joint reconstruction in unstable dorsal fracture-dislocations with > 50% of the articular surfaces. The most used graft is the dorsal hamate. Hemi-hamate arthroplasty is technically challenging and has anatomical incongruity, and many authors have evolved various modifications in the palmar buttress reconstruction of the middle phalanx base. Therefore, there are no universally accepted treatment modalities for these complex articular injuries. This article describes the dorsal capitate as the osteochondral graft for middle phalanx volar articular surface reconstruction. Hemi-capitate arthroplasty was done on a 40-year-old man with an unstable dorsal fracture dislocation of the PIP joint. The osteochondral capitate graft united well, and the joint congruency was good at the final follow-up. The surgical technique, illustrative images, and rehabilitation are discussed. With the evolving technical modifications and complications in Hemi-hamate arthroplasty, distal capitate may be considered a reliable and alternate osteochondral graft for unstable PIP joint fracture-dislocations. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00853-2.

Rib osteochondral graft for scaphoid proximal pole reconstruction.

BACKGROUND: An irreparable scaphoid proximal pole is challenging to treat because of the fragment size and limited blood supply. Salvage surgery, such as partial wrist fusion or proximal row carpectomy, may be performed but is not ideal for young patients. There are few reports of proximal scaphoid reconstruction using rib osteochondral grafts. METHODS: Four patients were treated with rib osteochondral graft for reconstruction of the scaphoid proximal pole. The patients had a mean postoperative follow-up of 24 months. The mean age at the time of surgery was 30 years. Outcome measurements included total active range of wrist motion arc, grip strength, and wrist function score. We also evaluated the progression of osteoarthritis and changes in carpal height. RESULTS: No complications occurred at the donor site. The range of motion improved from 82° to 95° before and after surgery. Grip strength improved from 22 kg to 33 kg before and after surgery. There was a remarkable improvement in the modified wrist function scores of Green and O'Brien from 40 points to 70 points before and after surgery. No progression of arthrosis was seen on the radiographs of all the patients. There was no significant difference in the carpal height ratio before and after surgery. CONCLUSIONS: Proximal scaphoid fractures may require reconstruction of the articular surfaces of the radius, capitate, and lunate. Reconstruction with a rib osteochondral graft is flexible, easy to fabricate, and can reconstruct the three articular surfaces.

Fixation of an Osteochondral Lesion of the Femoral Intercondylar Groove Using Autogenous Osteochondral Grafts and Bioabsorbable Pins in a Patient with Open Physes: A Case Report.

Osteochondral lesion (OCL) of the patellofemoral (PF) joint is not an uncommon cause of knee pain, and surgery is needed when conservative treatment fails. However, there is a lack of evidence regarding the optimal surgical treatment for OCL of the PF joint. Fixation of OCLs using autogenous osteochondral grafts has been reported to be effective for OCL of the knee. However, in this surgical technique, the biomechanical strength of osteochondral grafts may not be sufficient in patients with open physes due to the specific quality of the cartilage and subchondral bone given their age. There is a lack of studies reporting fixation of the OCL located in the PF joint using autogenous osteochondral grafts. We herein report a case of OCL of the femoral intercondylar groove where autogenous osteochondral grafts augmented with bioabsorbable pins were used to fix the lesion in a 14-year-old patient with open physes. Preoperative MRI revealed a completely detached OCL of the intercondylar groove (36 mm × 20 mm). Although a total of four osteochondral grafts were harvested from the non-weightbearing area of the lateral femoral condyle, cartilage detached from one of the grafts. The quality of the osteochondral grafts was considered to be insufficient for stabilization of the OCL; thus, two bioabsorbable pins were additionally inserted following fixation of the lesion using three osteochondral grafts. After two years of follow-up, postoperative functional scores were favorable without knee pain. The present case suggests that fixation of the OCL using autogenous osteochondral grafts may not be appropriate for young patients with open physes.

Knee osteochondritis dissecans-treatment technical aspects.

Purpose and objective: Current treatments of different stages of knee osteochondritis Dissecans (OCD) are depending on the age of the patients and the stability of the diseased osteochondral area. The purpose of this paper was to summarize the treatment alternatives in order to simplify the choice for the treating surgeon. Background and principle results: Osteochondritis dissecans (OCD) of the knee is an idiopathic and local osteochondral abnormality that affects mainly children and adolescents with risk of loosening of osteochondral fragments. A good clinical result can be expected when the physes are still open, when the osteochondritis is small and when the osteochondritis can be assessed as stable by MRI. Unstable OCD lesions most often need to be treated operatively by different fixation methods and when the osteochondral cannot be refixated, different local chondral and osteochondral repairs are available to fill up the defect area to congruity. Summary and major conclusions: The final choice of which treatment to use is depending on fragment viability and forms. Viable fragments are refixated while poor quality fragments are removed followed by a local biological osteochondral repair. Such osteochondral resurfacing may be single bone marrow stimulation with or without scaffold augmentation or different cell seeded grafts.

Management of Treatment Failures in Osteochondral Lesions of the Talus.

Osteochondral lesions of the talus are a common result of traumatic ankle injury. Due to the low success rates of nonoperative management, surgical management of osteochondral lesions of the talus (OLTs) has evolved considerably over the past decade as more outcomes research has emerged, new techniques have been described, and we have developed a better understanding of the role of biologics in the treatment algorithm. We describe, in sequence, the surgical management options, including salvage procedures, for failed treatment of OLTs.

Total Joint Arthroplasty of a Proximal Interphalangeal Joint with Proximal Metal Surface Replacement and Distal Hemi-Hamate Autograft: A Long-Term Follow-Up.

A 28-year-old female recreational athlete presented with middle finger proximal interphalangeal joint pain, stiffness, and ulnar deviation deformity 2 years after internal fixation of a middle phalanx base fracture-dislocation. Radiographs revealed posttraumatic changes on both sides of the proximal interphalangeal joint. Having failed nonsurgical measures, she elected to proceed with surgical reconstruction. Intraoperatively, we confirmed substantial articular damage on both sides of the joint. We proceeded with hemi-hamate autograft for 80% of the middle phalanx base. We used a cobalt chrome proximal phalanx component. After healing, the patient returned to all daily-living and athletic activities with resolution of preoperative pain, stiffness, and deformity. Twelve years after surgey, she had no pain or substantial limitations because of the finger. We measured 80° of proximal interphalangeal joint motion. The grip and fingertip-pinch strength were 91% and 73%, respectively, of the contralateral dominant hand. Radiographs showed no progressive changes compared to 3 years after surgery.

An evidence-based update on the management of articular cartilage defects in the hip.

Objective: Articular cartilage defects in the hip joint pose a significant surgical challenge and remain one of the most important determinants of success following arthroscopic intervention of the hip. The aim of this literature review was to report on the best available evidence on the various treatment options utilised for articular cartilage defects in the hip. Material and methods: A comprehensive literature search was performed on PubMed from its inception to October 2021 using the following search strategy: ((hip) and (cartilage or chondral) and (repair or regeneration or restoration or implantation or chondroplasty or chondrogenic)). Two reviewers (KHSK, MG) independently reviewed titles and abstracts to identify articles for the final analysis. Articles were included if they were original research studies (randomised control trials, cohort studies, case-control studies, or comparative studies) on treatment of hip cartilage defects in humans reporting on a minimum of 5 patients. A total of 1172 articles were identified from the initial literature search. Following a thorough selection process, 35 articles were included in the final analysis to synthesise the evidence. Results: Debridement, microfracture, autologous chondocyte implanatation (ACI) and matrix-induced ACI (MACI) are shown to have good short-to medium-term results. Injectable ACI and MACI have been developed to enable these procedures to be performed via arthroscopic surgery to reduce the post-operative morbidity associated with surgery with promising early results. Large cartilage defects which involved the sub-chondral bone may need the use of osteochondral grafts either autograft or allograft. Newer biological solutions have been developed to potentially deliver a single-stage procedure for hip cartilage injuries but longer-term results are still awaited. Conclusion: Accurate identification of the extent of the injury helps stratify the defect and plan appropriate treatment. Several surgical techniques have shown good short to medium-term outcomes with ACI, AMIC, mosaicplasty and microfracture. Recent advances have enabled the use of injectable MACI and bioscaffolds which show promising results but in the shorter term. However, one needs to be mindful of the techniques which can be used in their surgical setting with the available resources. In order to thoroughly evaluate the benefits of the different surgical techniques for hip cartilage defects, large scale prospective multi-centre studies are necessary. Perhaps inclusion of such procedures in registries may also yield meaningful and pragmatic results.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus.

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs. HYPOTHESIS: The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol. MATERIALS AND METHOD: This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated. RESULTS: No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series. DISCUSSION: There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded. LEVEL OF EVIDENCE: IV.

A Morphometric Analysis of Hamate Autograft for Proximal Scaphoid Reconstruction.

Objective Recently, authors have investigated using the proximal hamate as osteochondral autograft for proximal pole scaphoid reconstruction in the case of nonunion with avascular necrosis. The aim of our study was to analyze the morphology and anatomic fit of the proximal hamate compared with the proximal pole of the scaphoid using cadaveric specimens. Materials and Methods Ten cadaver specimens (five males and five females) were dissected. Scaphoid and proximal hamate bones were measured by two independent investigators using electronic calipers and radius of curvature gauges. After measurements were determined to have good correlation, the average value of the two observers' measurements were used for further analysis. Sagittal radius of curvature (ROC), coronal ROC, depth, width, and maximum graft length were compared. Results The average depth of the scaphoid proximal pole was 12.3 mm (standard deviation [SD] = 1.12) compared with 11.3 mm (SD = 1.24) for the proximal hamate ( p = 0.36). The average width was 7.8 mm (SD = 1.00) in the scaphoids compared with 8.6 (SD = 1.05) in the hamates ( p = 0.09). There was also no significant difference in the sagittal ROC between hamates (9.1 mm, SD = 1.13) and scaphoids (9.5 mm, SD = 0.84; p = 0.36). All of these average measurements were within 1 mm. There was a significant difference between the coronal ROC of the hamate (23.4 mm) and scaphoid (21.1 mm) bones in our samples ( p = 0.03). Females were on average smaller than their males, but there was no significant difference in fit based on sex alone. Conclusion The proximal pole of the hamate has similar morphology and size as the scaphoid, with similar depth, width, and sagittal ROC. It has potential as an osteochondral autograft for proximal pole scaphoid reconstruction.

Three-and-a-half to 18 year outcome data for costal osteochondral grafts for salvage of the proximal pole of the scaphoid.

Twelve patients who had undergone costal osteochondral graft reconstruction of the proximal pole of scaphoid were evaluated with clinical examination, patient-reported outcome scores and radiographs with an average follow-up of 10 years (range 3.5-18). The range of wrist motion was not significantly changed compared with the preoperative range of motion and functional outcomes scores were acceptable. The patients reported low pain scores despite the universal presence of radiographic changes of reduced carpal height and arthritis of the midcarpal and radiocarpal joints. Costal osteochondral graft reconstruction of the proximal pole of scaphoid offers good long-term pain relief and function.Level of evidence: IV.

A triplanar osteotomy technique in arthroscopy-assisted ankle mosaicplasty.

PURPOSE: Osteochondral lesions of the talus are lesions that are seen particularly in the young age group and are often related to sports injuries and trauma. These lesions, which show late symptoms radiologically, can be determined in the early stages with magnetic resonance imaging. The aim of this study was to present a new osteotomy technique to reduce the complications of mosaicplasty surgery to a minimum and provide an early return to work. METHODS: A total of 11 patients who had cartilage lesions due to osteochondritis dissecans in the medial aspect of the talus underwent mosaicplasty after a triplanar osteotomy. The dimensions of the lesion and the depth of the triplanar osteotomy were determined preoperatively. Coronal, sagittal and transverse cuts were made at the depth defined arthroscopically. Following the osteotomy, an osteochondral graft taken from the ipsilateral knee was placed in the prepared area. Osteotomy side was fixed with one or two cannulated screws following mosaicplasty. RESULTS: With this technique, weight-bearing can be immediate in cases with no need for osteotomy in the joint surface. In cases including the joint surface, partial weight-bearing is permitted after 4 weeks and can be increased as tolerated. In the 11 cases treated with this technique, full weight-bearing was achieved at mean 5 weeks (range, 5-8 weeks). No shift (upward displacement of osteotomized fragment) or non-union was seen in any patient. CONCLUSION: With the triplanar osteotomy technique described here, potential shift complications can be reduced to a minimum. As only the lesion region is targeted, the osteochondral surface formed by the fracture is much less. STUDY DESIGN: Case Series; Level of Evidence, 4.